BY B. F. JOSLIN, JR., M. D., NEW YORK.

The case which I now report possesses considerable interest from the peculiar nature of the disease, as well as from the fact that a nearly complete history of it can be given as from the earliest signs of disease, until the final termination (with the exception of a few weeks) the patient was under my care. The post mortem examination, which revealed the probable cause of the symptoms, will also be published.

Although not in the final result successful, it still illustrates the truest method of palliation — that of relieving the disease as far as possible by appropriate medicines. During its progress it afforded many illustrations of the efficacy of attenuated medicines, administered according to the plan of allowing the symptoms to indicate the remedy. Now that we have the whole case in review, it is difficult to surmise what other plan of treatment could have been adopted, or what better course, could have been pursued if any one had been in possession of all the information elicited by the post mortem examination.

The prominent symptom of the case was difficulty of deglutition, not constant as from permanent stricture of the esophagus, but variable in its degree and time of occurrence. First appearing about three years and a half since and continuing several weeks, then apparently giving way to treatment, and after the lapse of nearly three years, during which period she enjoyed good health most of the time, reappearing and continuing with intermissions of only a few days at a time, until the patient died of inanition.

Such is a general outline of the case; and before proceeding further I wish to say something in regard to the diagnosis. At the time of the first appearance of the disease three years since, I considered it as purely nervous and not of serious importance; the temporary recovery which shortly after occurred, seemed to corrobate this diagnosis and prognosis. I never saw any reason to change my diagnosis, but after I had treated her for sometime, subsequently to the re-appearance of the symptoms, I came to the knowledge of certain facts which together with the additional fact that my patient was not improving, led me to think more seriously of the case.

I learned that the father of this patient died with apparently the same disease — inability to swallow, accompanied, in his case, with some indications of insanity. He died quite suddenly after only a few weeks continuance of the disorder; while she lingered out a painful existence for months.

The patient was a lady, twenty-eight years of age at the time of her death. She was of rather nervous temperament. Her menses were usually scanty, and bowels inclined to constipation. She mentioned to me during her last sickness that for some months previously, she had been in the habit of taking quite strong coffee, which I have no doubt increased her nervous irritability.

To show the distinction between this case and one of ordinary spasmodic stricture of the esophagus, I will quote a few lines from Habershon on Diseases of the Alimentary Canal. He says, “The few cases of this kind which have come under my own observation, have been in young women of an excitable nervous system, with leucorrhea or painful menstruation and impaired digestion. The strongest language was used by these patients to express their inability to swallow, and they showed the greatest unwillingness even to attempt it. * * * * The general symptoms and history aid us in the diagnosis of these cases, as the absence of emaciation, the suddenness of the attack after a slight cause, as nervous shock or slight catarrh; the absence of pain; the existence of considerable nervous excitement. “In the case which I report, emaciation was regularly progressive during the last four months of the patient's life.

The first record I have of the principal symptom of this case is on September 8th, 1856. She then told me, that on the previous evening, she had a “choking in the throat,” relieved after taking salt and water. Three days before she had complained of burning in stomach and abdomen, and weakness in stomach and of feeling “nervous.” I had given her Sulph^.20 with benefit. Her bowels were quite constipated, as was frequently the case with her. I prescribed Opium².

She continued to be troubled with the choking sensation in throat on attempting to swallow any thing solid, until the 26th instant. During this period I gave her Carb. an^.20, Nux⁴, Con^.20, Puls^.20 and Merc³⁰, under the last mentioned of which remedies improvement took place. On making an effort to cough, about this time, to remove the obstruction in the throat she raised blood. During this period, I have also recorded the following symptoms: —

Sensation of a lump in throat; constant sour taste in mouth, and sometimes sour eructations; oppression at pit of stomach; heaviness and fulness in head; vertigo in morning; easily excited; ulcers on tongue, for a day or two; sharp pain in left iliac region extending to thigh, increased by motion; menses scanty and delayed.

On the evening of the 26th, she was able to eat solid food after an enforced abstinence of many days. On the 27th, I gave her Plumb^.20 She continued to improve, and on November 2nd, I record: — Can swallow without difficulty; bowels still costive. Gave Opium.²

November 6th. Bowels less costive; about 4, p.m., daily, has congestion in the head; face red, with sensation of fulness in head attended with nervous excitability. Prescribed, Bell.³⁰

November 22nd. Return of pain in throat. Bell.²⁰

November 24th. Sensation of choking in throat, with oppression in upper part of chest; feels unwilling to take solid food for fear it would choke her. Rhus.²⁰ November 26th. Better. Continued Rhus.

December 4th. Fulness in head; wild feeling. This morning palpitation and sensation of heat rising upward in chest. Bell.¹⁰

December 13th. Throat more troublesome than ever. Complaint returned on the 6th instant. Head relieved by Bell.¹⁰ She has observed the affections of head and throat to alternate.

Has sharp pains in right side of esophagus, about an inch below the lower jaw. Thinks she cannot swallow solid food; has not taken any for a week; lives on soft toast. Has at times fluttering palpitation, with faintness and sharp pain in one spot of chest. Puls.³⁰

December 16th. Better. Puls.³⁰

December 20th. Menses on 17th and 18th instants were very slight as usual. Complains of pain and oppression in chest, more on left side; pains extend to neck, and to left arm, and to thumb. Sensation in neck and upper extremities as of drawing. No trouble in throat, except that after eating a sensation of rising; has fluttering in left chest; feels quite low spirited; imagines she has disease of heart; horrible dreams; tongue brown; constipation. 2 Sulph.³⁰

December 23rd. Better. Sach. lact.

December 29th. Soreness and aching in left hypochondrium, extending to abdomen; sour eructations and sour taste in mouth; after eating, salivation. 1 Nux.⁰ and Sulph.³⁰

After this I was not called upon to prescribed for her, until after an interval of six months, that is, July 6th of the following year, 1857. She then had neuralgic pains in the face, for which Puls.³⁰ was given. Said she was quite relieved of her old troubles, including constipation and menstrual difficulties.

I may as well mention, that I had occasionally seen her during this period, as other members of the family required my services.

After nearly a year of good health, on May 22nd, 1858, she called at my office, and said that after dinner her face was flushed and she had head-ache; burning in head and face, bowels costive. I prescribed Nux⁶, which I have no doubt relieved her, as I did not prescribe for her again till August 12th, when she complained of burning in the pit of stomach; nausea, more after eating; had once or twice vomited bitter and sour matter; constipation; vertigo in morning on rising; burning in face and eyes, with redness of face and suffusion of eyes. Bry.⁷, a dose morning and evening for a week, was prescribed.

July 14th, 1859, I record: — For about two weeks past has been troubled with sleeplessness; also a sensation of choking in throat, similar to former trouble; feels week. Bell.¹² was prescribed.

It will be seen by the record that she had been free from the choking more than two years and a half.

While attending another patient in the family, in the month of October, of the same year, I was requested to prescribe for her. She was under my care from the 13th to the 25th of October, when not being much improved She concluded to try some “bitters” recommended by a kind friend.

On the 13th of October, she had not eaten any thing for several days excepting a very small portion in the morning; at other times, was wholly unable to swallow even water or tea. She would say she felt perfectly well, with this singular exception. She did not have at this time the indications of disorder in regard to the function of digestion, which I have recorded previously, and which occurred subsequently after allopathic treatment. The only symptom besides the difficulty of deglutition, was her old trouble — constipation.

During the period from 13th to 25th October, she improved slightly, a few times being able to swallow a little food at dinner. The bowels were during a portion of this time pretty regular. The remedies prescribed during this period were Opium¹, which relieved constipation partially; Bell. ¹², with benefit to the throat symptoms; Alum¹², Nux⁰, and Cham.³⁰

On the 13th of November, nearly three weeks after, she sent for me. I found she had been under the care of an old school physician, but had not experienced the slightest benefit. Even the bowels would not yield to the action of Cathartics. She could eat a little more in morning, but none at any other time. I found her in bed; previously she had been up and about. Had this evening, faintness; nausea and palpitation, and sensation as though she could not get her breath. Tongue red anteriorly, but brown posteriorly. Gave her Ign.¹² solution, a dose every two hours.

On the 14th, had slept better than of late. Had slight nausea, and distress across epigastrium. Continued Ign.¹²

November 16th. Much better. Had taken food two or three times a-day. No difficulty in deglutition. Spirits much improved. Continued Ign.¹²

November 21st. Not so well for three or four days. Sour and bitter eructations after eating. Last night had faintness with cold sweat on forehead; hands and feet cold most of the time; menses delayed; should have appeared a week ago; pulse 96. Gave Bell^.20 solution, a dose every three hours.

November 22nd. Feels better; ate a good breakfast; has felt well since; pulse 68. Continued Bell.³⁰

November 23rd. Better; ate three meals yesterday; after eating soup at dinner had sour eructations. Continued Bell.³⁰

November 24th. Not so well; has not been able to eat anything since yesterday; sour eructations. Gave Bell.¹² solution, a dose every three hours.

November 26th. Not able to eat; last night after swallowing a little food had sour eructations, which prevented her from eating more; complains of flatulence in abdomen; passes urine quite frequently. Continued Bell.¹²

November 27th. Sensation of fulness in left iliac region, has had this symptom for a long time; ate at dinner yesterday and this morning at breakfast; took an enema yesterday, of water, with great relief to symptoms. Continued Bell.¹²

November 28th. Yesterday ate well at breakfast, dinner and tea. This morning fulness in pit of stomach. Gave Nux³⁰ solution, a dose every three hours.

November 29th. Not so well; scarcely able to eat anything at breakfast, could eat nothing at noon. Bell.³⁰ was given, solution every three hours.

November 30th. Rather better; ate a bowl of broth at dinner. Continued Bell.³⁰.

December 1st. Has now, after eating, spitting of thick tenacious matter, appearing like white of an egg beat up; sensation as if there were something which ought to come up; relaxation of joints; last night was awoke with griping in abdomen; tongue dry and stiff; feels much discouraged; pulse 66, of fair size and strength. Gave Nat. mur.^30, a dose every three hours.

December 2nd. Rather better; ate broth for breakfast and dinner; pulse 92. Continued Nat. mur.³⁰

December 3rd. Same as yesterday. Continued Nat mur.³⁰

December 4th. Ate three times yesterday, twice (so far) today. After dinner, at which she ate broth and corn starch pudding, expectorated much mucous. Continued Nat. mur.³⁰

December 5th. Ate at breakfast and dinner. Continued Nat. mur. ³⁵

December 6th. Has sat up from 6, a.m., till the present time, 4 p.m.; ate well. Continued Nat. mur.³⁰

December 7th. Took some cider today, and since then has had burning in esophagus; appetite pretty good; ate a whole roll at breakfast. Gave I Merc. ³⁰ and continued Nat. mur.³⁰

December 9th. Has been able to eat much better than usual; her broth is made thicker; she also ate half a potatoe, the first in more than two months. Feels rather weaker; tongue clean; pulse 64. Continued Nat. mur.³⁰

December 11th. Since last date eructations after eating; tongue coated brown. Sulph.³⁰, a dose every three hours.

December 12th. Only able to take a cup of tea at dinner today; yesterday ate some beef, chewing the meat and swallowing the juice; pulse 72. Gave Verat¹² solution, a dose every three hours.

December 13th. Today has scarcely swallowed anything, only a little water and a few tea-spoonfuls of weak broth. On endeavouring to swallow had choking. Rumbling in abdomen. It seems to her as though there were wind in abdomen which prevented her from swallowing. Pulse 58. Baryta carb ^.30 solution, every three hours.

December 14th. Same as yesterday but weaker. Aching in eyes; soreness of lowest floating rib, on left side. Gave Chain^.30 every two hours.

December 15th. Same. After eating some ice cream had dyspnea. Did not sleep well. Gave Nux³⁰ every three hours.

I called on the 16th, but learned she had concluded to return to her old school physician. She continued under his care until a few days before her death, which took place February 25th, 1860. As I understood from mutual friends that she had expressed a desire to see me, and that her physician had given up all hopes of curing her, I made a friendly call on the 21st of February. The physician had left several days before, saying that it was useless to give her any more medicine as she was dying. On the 16th, she had taken about two drops of beef tea but had not taken a particle of any thing since. She was as much emaciated as any one could be and so weak that she was unable to turn herself in bed, but her voice wag clear and distinct; had at times been unable to speak. As she wished me to give her something to relieve a burning in throat and extreme dryness in mouth of which she complained, I gave her some pellets of Ars.³⁰

On the 23rd, I was called in haste at half-past six o'clock, a.m. She had been suffering extremely severe pains in abdomen, since 11, p.m.; her pulse was very small and rapid; several remedies were given but appearing not to relieve her I allowed her to inhale Sulphuric Ether, which very greatly relieved her pain. This was occasionally repeated and a few pellets of Nux⁶ placed in her mouth. Death finally came and relieved her of her sufferings, but the access to it was extremely gradual. When I saw her on the morning of the 23rd, I did not suppose she could live out the day: her hands and feet were cold, and her pulse too frequent to be counted, notwithstanding which, her voice was quite distinct. She retained her consciousness till the last, but for thirty-six hours before her death could not speak.

As some may wonder why the esophageal bougie was not introduced and so afford means of getting food into the stomach, I will state that I had thought of it before my attendance ceased, in December 1859, but the symptoms were scarcely severe enough to warrant it. When I saw her a few days before her death, she was altogether too far gone to give any chance for her recovery. I should have tried it as an experiment without having any confidence in its success, as it was evident, during the latter part of her sickness, that the stomach did not perform its functions for the small amount of food which was swallowed.

Nutritive enemata were tried.

The Post mortem Examination was made by Dr. Snelling and myself, the results were as follows: —

Emaciation extreme; pectoral muscles much wasted; lungs pale but healthy; no tubercles; coats of stomach seemed thicker than is usual; peritoneum unusually thick and tough so as to be torn with difficulty; liver large but normal; spleen small; kidneys normal; the veins of the intestines were full, as were also those on external surface of uterus. A number of small lumps of feces were found in bowels.

So far nothing was found to account for her death or even for most of the symptoms observable during life.

We then proceeded to examine the esophagus, for which purposes we removed both clavicles. On dissecting about the lower part of trachea, a small hard tumour was discovered, which proved to be osseous in its character. It was about an inch long and a half inch in breadth and thickness, it was hard and solid with numerous spiculae of bone projecting from it. It was situated just above the bifurcation of trachea, inclined to the right side; a nerve was seen to be very intimately connected with the tumour, being on its anterior surface, this I considered to be a cardiac branch of the pneumogastric nerve. By the interference with the functions of this nerve was probably the peculiar difficulty of deglutition produced, as also the symptoms of disorder in the digestive apparatus.

A number of small spiculae of bone were found among the numerous vessels, immediately around the larger tumour.

The tumour did not press on the esophagus and was only loosely attached to trachea; it was firmly adherent to the posterior portion of the vena cava superior; it could only be implicated in the production of the symptoms by its relations with the pneumogastric nerve.

I made a preparation of the tumour with some of the adjacent parts, which is now in my possession.

Some interesting connections might be traced between the symptoms and the pathological changes, which may possibly form the subject for a future article.

In conclusion, I will state that the only remedies which produced a marked effect upon the difficulty of deglutition, were Mercurius, Pulsatilla, Ignatia, Belladonna and Natrum muriaticum, From the larger edition of Jahr's Manual I extract the following symptoms of the pathogenesis of these drugs*[The Italics and other Distinctive Marks are from Jahr.]

MERCURIUS. — Sensation as if something had lodged in throat.

*Difficult deglutition. He had to press very hard to get something down. Spasmodic difficulty of swallowing with danger of suffocation. Aching pain in the esophagus.

PULSATILLA. — * Sensation on swallowing, as if the back part of throat were narrower than usual or closed by swelling. Sensation as if the pharynx were swollen.

* When swallowing he feels as if the throat were swollen, Difficulty of swallowing as if from paralysis of the muscles of deglutition. Choking pain in the pharynx as if from swallowing too large a morsel.

IGNATIA. — * Sensation when swallowing as if one swallowed over a lump. Strangulating sensation in the middle of the fauces as if a large lump had lodged in throat.

* Difficulty of swallowing solid or liquid food.

BELLADONNA. — Sensation as of a lump which cannot be removed.

* Impeded deglutition or entire inability to swallow even liquids. Short lasting but frequently recurring contraction of the esophagus.

* When swallowing, one experiences a sensation in the throat as though the parts were too narrow, contracted as if nothing would go down. Pressure in throat with choking ascending from abdomen.

NATRUM MURIATICUM. — Sensation as if a plug had lodged in the throat. Spasms in the pharynx; when swallowing she found it very difficult to get the food down or to bring it up again, so that she came near suffocating. Constriction of right side of throat, the pain extending to neck.

While engaged in writing out this case, a young woman came under my care at the Central Homoeopathic Dispensary, whose case presents some points of resemblance to it. She has had extreme difficulty in the deglutition of solids for a year or more, with progressive loss of strength and emaciation. She has been so far slightly benefited. Should she remain under my care, I shall report the result at some future time.

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